Real-world evidence of neoadjuvant chemotherapy for breast cancer treatment in a Brazilian multicenter cohort: Correlation of pathological complete response with overall survival

OBJECTIVES

We aimed to evaluate the pCR rate in patients receiving NAC for the treatment of breast cancer (BC) in a multicenter cohort in Brazil. Additionally, we aimed to use RWD to assess the impact of pCR on OS and DFS.

METHODS

This was a retrospective, multicenter cohort study that included female patients over 18 years of age who were diagnosed with nonmetastatic breast cancer and received NAC. OS and DFS at five years were estimated by the Kaplan‒Meier method. Additionally, we conducted a multivariate analysis to identify factors that were significantly associated with pCR and OS.

RESULTS

From 2011 to 2020, 1891 patients were included in the study, and 421 (22,3%) achieved pCR (ypT0 ypN0). Considering the presence of residual DCIS, pCR was achieved in 467 patients (23,5%). The pCR rate varied between the subtypes: HER-2+ (p = 0,016) and clinical stage IIIA and IIIB (p < 0,001). Among HER-2+ patients, those who received trastuzumab had a significantly higher pCR rate than those who did not receive trastuzumab (p < 0.0001). Similarly, patients with TNBC who received treatment with platinum-based regimens also showed higher pCR rates (p < 0.0001). OS was grouped according to pCR status, and the OS rate was 88,3% in the pCR group and 58.1% in the non-pCR group (p < 0.0001). The five-year DFS was 92.2% in the pCR group and 64.3% in the non-pCR group (p < 0.0001).

CONCLUSION

The pCR rate and its prognostic value varied across BC subtypes. In our study, pCR could be used as a surrogate of favorable clinical outcome, as it was associated with higher OS and DFS rates.

Increased Expression of miR-223-3p and miR-375-3p and Anti-Inflammatory Activity in HDL of Newly Diagnosed Women in Advanced Stages of Breast Cancer

The expression of inflammation-related miRs bound to high-density lipoproteins (HDLs), the anti-inflammatory activity of HDLs isolated from individuals with breast cancer, and controls were determined. Forty newly diagnosed women with breast cancer naïve of treatment and 10 control participants were included. Cholesterol-loaded bone-marrow-derived macrophages were incubated with HDL from both groups and challenged with lipopolysaccharide (LPS). Interleukin 6 (IL6) and tumor necrosis factor (TNF) in the medium were quantified. The miRs in HDLs were determined by RT-qPCR. Age, body mass index, menopausal status, plasma lipids, and HDL composition were similar between groups. The ability of HDL to inhibit IL6 and TNF production was higher in breast cancer compared to controls, especially in advanced stages of the disease. The miR-223-3p and 375-3p were higher in the HDLs of breast cancer independent of the histological type of the tumor and had a high discriminatory power between breast cancer and controls. The miR-375-3p was greater in the advanced stages of the disease and was inversely correlated with the secretion of inflammatory cytokines. Inflammation-related miRs and the anti-inflammatory role of HDLs may have a significant impact on breast cancer pathophysiology.

Current Challenges and Perspectives in Breast Cancer in Elderly Women: The Senologic International Society (SIS) Survey

Objective

Mammographic screening and management of breast cancer (BC) in elderly women are controversial and continue to be an important health problem. To investigate, through members of the Senologic International Society (SIS), the current global practices in BC in elderly women, highlighting topics of debate and suggesting perspectives.

Materials and Methods

The questionnaire was sent to the SIS network and included 55 questions on definitions of an elderly woman, BC epidemiology, screening, clinical and pathological characteristics, therapeutic management in elderly women, onco-geriatric assessment and perspectives.

Results

Twenty-eight respondents from 21 countries and six continents, representing a population of 2.86 billion, completed and submitted the survey. Most respondents considered women 70 years and older to be elderly. In most countries, BC was often diagnosed at an advanced stage compared to younger women, and age-related mortality was high. For this reason, participants recommended that personalized screening be continued in elderly women with a long life expectancy.In addition, this survey highlighted that geriatric frailty assessment tools and comprehensive geriatric evaluations needed to be used more and should be developed to avoid undertreatment. Similarly, multidisciplinary meetings dedicated to elderly women with BC should be encouraged to avoid under- and over-treatment and to increase their participation in clinical trials.

Conclusion

Due to increased life expectancy, BC in elderly women will become a more important field in public health. Therefore, screening, personalized treatment, and comprehensive geriatric assessment should be the cornerstones of future practice to avoid the current excess of age-related mortality. This survey described, through members of the SIS, a global picture of current international practices in BC in elderly women.

Increased plasma lipids in triple-negative breast cancer and impairment in HDL functionality in advanced stages of tumors

The association between plasma lipids and breast cancer (BC) has been extensively explored although results are still conflicting especially regarding the relationship with high-density lipoprotein cholesterol (HDLc) levels. HDL mediates cholesterol and oxysterol removal from cells limiting sterols necessary for tumor growth, inflammation, and metastasis and this may not be reflected by measuring HDLc. We addressed recently diagnosed, treatment-naïve BC women (n = 163), classified according to molecular types of tumors and clinical stages of the disease, in comparison to control women (CTR; n = 150) regarding plasma lipids and lipoproteins, HDL functionality and composition in lipids, oxysterols, and apo A-I. HDL was isolated by plasma discontinuous density gradient ultracentrifugation. Lipids (total cholesterol, TC; triglycerides, TG; and phospholipids, PL) were determined by enzymatic assays, apo A-I by immunoturbidimetry, and oxysterols (27, 25, and 24-hydroxycholesterol), by gas chromatography coupled with mass spectrometry. HDL-mediated cell cholesterol removal was determined in macrophages previously overloaded with cholesterol and ¹⁴C-cholesterol. Lipid profile was similar between CTR and BC groups after adjustment per age. In the BC group, lower concentrations of TC (84%), TG (93%), PL (89%), and 27-hydroxicholesterol (61%) were observed in HDL, although the lipoprotein ability in removing cell cholesterol was similar to HDL from CRT. Triple-negative (TN) BC cases presented higher levels of TC, TG, apoB, and non-HDLc when compared to other molecular types. Impaired HDL functionality was observed in more advanced BC cases (stages III and IV), as cholesterol efflux was around 28% lower as compared to stages I and II. The altered lipid profile in TN cases may contribute to channeling lipids to tumor development in a hystotype with a more aggressive clinical history. Moreover, findings reinforce the dissociation between plasma levels of HDLc and HDL functionality in determining BC outcomes.

The increased antioxidant action of HDL is independent of HDL cholesterol plasma levels in triple-negative breast cancer

Introduction

The association between high-density lipoprotein cholesterol (HDLc) with the incidence and progression of breast cancer (BC) is controversial. HDL removes excess cholesterol from cells and acts as an antioxidant and anti-inflammatory. BC is a heterogeneous disease, and its molecular classification is important in the prediction of clinical and therapeutic evolution. Triple-negative breast cancer (TNBC) presents higher malignancy, lower therapeutic response, and survival rate. In the present investigation, the composition and antioxidant activity of isolated HDL was assessed in women with TNBC compared to controls.

Methods

Twenty-seven women with a recent diagnosis of TNBC, without prior treatment, and 27 healthy women (control group) paired by age and body mass index (BMI) were included in the study. HDL and low-density lipoprotein (LDL) were isolated from plasma by discontinuous density gradient ultracentrifugation. Plasma lipid profile and HDL composition (total cholesterol, TC; triglycerides, TG; HDLc; phospholipids, PL) were determined by enzymatic colorimetric methods. ApoB and apo A-I were quantified by immunoturbidimetry. The antioxidant activity of HDL was determined by measuring the lag time phase for LDL oxidation and the maximal rate of conjugated dienes formation in LDL incubated with copper sulfate solution. The absorbance (234 nm) was monitored at 37°C, for 4 h, at 3 min intervals.

Results

The control group was similar to the TNBC concerning menopausal status, concentrations, and ratios of plasma lipids. The composition of the HDL particle in TC, TG, PL, and apo A-I was also similar between the groups. The ability of HDL to retard LDL oxidation was 22% greater in the TNBC group as compared to the control and positively correlated with apoA-I in HDL. Moreover, the antioxidant activity of HDL was greater in the advanced stages of TNBC (stages III and IV) compared to the control group. The maximum rate of formation of conjugated dienes was similar between groups and the clinical stages of the disease.

Discussion

The results highlight the role of HDL as an antioxidant defense in TNBC independently of HDLc plasma levels. The improved antioxidant activity of HDL, reflected by retardation in LDL oxidation, could contribute to limiting oxidative and inflammatory stress in advanced stages of TNBC.

Abstract P4-07-41: Is axillary evaluation still necessary in DCIS?

Background Ductal carcinoma-in-situ (DCIS) is a growing health problem in the world. Before the advent of screening mammography, the incidence of DCIS was low, and patients presented with DCIS that had become clinically symptomatic. Upon this evidence, a strategy of aggressive surgical therapy like the approach with invasive cancer was adopted. The status of the regional lymph nodes is the most important prognostic factor and predictor of survival in breast cancer, but as DCIS is a malignant proliferation of the epithelial inside the breast duct and, therefore, does not have the capacity to generate metastasis. However, an upstaging after surgery is possible. The need for sentinel node biopsy (SNB) in patients with a preoperative biopsy diagnosis of DCIS is still controversial but is done in selected cases. Objectives Our main objective in this study was to evaluate the surgical approach in the axilla (SNB or axillary dissection – AD) of patients diagnosed with DCIS in a single institution and describe the surgical treatment (mastectomy or breast conservative surgery – BCS). In addition, we aimed to find the reasons that led our surgeons to choose one or the other treatment. Methods A retrospective analysis was made using the Pérola Byington Hospital’s database, from January 2011 to December 2019. During this period, 11,373 cases of breast cancer were treated int the institution and 812 (7.4%) were DCIS. Data was available and we could analyze 494 patients who underwent core biopsy or vacuum-guided biopsy guided by mammography or ultrasound and were diagnosed with DCIS and underwent surgical treatment at the Hospital. We grouped the patients into 3 age groups: under 40, 40-49, and 50 and over. In all groups, we had patients who underwent SNB using the patent blue technique or axillary dissection (AD) and were evaluated using the H&E method. We had also evaluated the type of surgery (BCS or mastectomy) in each age group. Results DCIS was diagnosed through mammographic alterations in 62% of all cases and nuclear grade 2 was the most common, with 47%, followed by grade 3 and 1, 46% and 4%, respectively. In 2% of cases the data was missing. Comedonecrosis was present in 78% of our specimens. The type of surgery (radical or BCS) was evaluated and BCS was made in 360 patients (72,87% of the cases), with the axillary approach being performed in 125 patients of these patients (50,20% of cases that went to axillary approach including 9 patients that were submitted to AD). In 27,1% the surgical approach was a radical surgery (total mastectomy or skin sparing mastectomy) and in this group 92,5% were submitted to axillary approach. There was a strong correlation in the type of surgery and axillary approach (p-value 0,000) In the group of patients younger than 40 years, 74% of patients (17 out of 23 in total) underwent an axillary approach regardless of the type of surgery (p-value 0.036) When evaluating the predetermined age groups, we saw that most of our patients were 50 years or more (69%), followed by patients between 40-49 years (26%) and 5% in patients under 40 years. In only 3% of cases (16 in 494) we reclassified the lesion as invasive carcinoma after the surgery. None of them had a lymph node involved by malignant cells after surgery and that’s include the cases reclassified as invasive carcinoma. Conclusion The results obtained in this analysis showing no axillary involvement will make us rethink the indications for the concomitant surgical approach of the breast and the axilla in cases with a diagnosis of DCIS to reduce the axillary surgical overtreatment. It was not our goal to compare the costs, mobility, and complications of the surgical treatment as the survival in these patients that can be addressed in another studies.

Citation Format: Marcellus Ramos, Andre Mattar, Andressa Amorim, Felipe Cavagna, Mariana Passos, Raquel Fernandes, Jorge Shida, Luiz Henrique Gebrim. Is axillary evaluation still necessary in DCIS? [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P4-07-41.

Abstract P3-03-20: Breast cancer stage, molecular subtype and survival in patients with obesity: a Brazilian cohort study

Background Breast cancer (BC) continues to be highly prevalent and lethal among women worldwide. Obesity is an established risk factor for several types of cancer, including BC, particularly in postmenopausal women. Obesity may also be a prognostic factor for BC in all ages, as it increases the risk of surgery complication, decreases the response to chemotherapy, and increases mortality. This study aimed to evaluate if obesity was related to poor prognosis of patients with BC in Brazil. Methods In this retrospective, single center, cohort study, an electronic database from Pérola Byington Hospital (in São Paulo, SP, Brazil) was used to select patients with BC followed between January 2011 and June 2021. All included women had a confirmed diagnosis of BC and were divided in four groups according to BMI categories, defined by weight (kg)/height2 (m): &lt; 18.5 kg/m2: underweight; 18.5 to &lt; 25 kg/m2: healthy weight; 25 to &lt; 30 kg/m2: overweight; ≥30 kg/m2: obese. This study was approved by the local Institutional Review Board. Outcomes The overall survival (OS) was the primary outcome, evaluated by the comparison of the incidence of death from BC among groups. Progression-free disease survival (PFS) was also measured. Statistic methods The descriptive analysis was expressed as continuous variables in summary measures (mean, median, standard deviation, and quartiles), while categorical variables were expressed in frequencies and percentages. The Kaplan-Meier method was used for survival graphs, the Log-rank method to evaluate the difference between the survival curves, and Cox regression to calculate the hazard ratio (HR) and OR for death. The significance level adopted in the tests was 0.05, two-tailed hypotheses considered, and the confidence intervals (CI) constructed are 95%. R version 4.1.1 software was used to carry out all analyses. Results A total of 10,117 patients were screened, 7,424 were included, and 6,992 were considered for the survival analysis. The mean age was 55.12 ±12.47 years at diagnosis and the mean BMI was 27.97 ±5.55 kg/m2. Patients with obesity corresponded to 30.81% of the study population, and 64.82% of them were ≥ 50 years old (postmenopausal), p &lt; 0.001. For each BMI group, most patients were postmenopausal, p&lt; 0.001; without significant difference among groups, p=0.2133. Considering staging by breast (n=6,872), 42.97% of the underweight group were stage III; 41.90% of the healthy weight, 42.79% of overweight, and 39.38% of obese groups were stage II, p &lt; 0.001 (within-group), and p=0.0944 among groups. Molecular subtype did not differ neither within the group (p=0.068) nor among groups, p=0.1155. A total of 6,992 patients were included in the survival analyses, corresponding to 7,090 breasts. During the 10 years-follow up, 265 patients (3.79 %) died from BC. Figure 2 shows the Kaplan–Meier estimates of OS according to BMI, p=0.12. There was no difference in OS according to menopausal status. According to the multivariate Cox-regression analysis results, none of the variables evaluated significantly impacted the OS of patients with BC. BMI did not significantly impact the results. The variables that significantly impacted the chances of pCR were HER2+ and triple-negative compared with luminal A, staging zero compared with I, recurrence, adjuvant therapy, age, and time between diagnosis and surgery. Conclusion In conclusion, obesity did not impact the survival or progression of BC in this retrospective analyses. This study, despite not demonstrating significance in its primary objective, brings important epidemiological data from the Brazilian population with BC not previously published, with high prevalence of overweight and obesity among Brazilian women with BC and highlights the importance of further studies, especially prospective, addressing obesity and BC.

Citation Format: ANDRE MATTAR, Larissa Chrispim, Felipe Cavagna, Luiz Henrique Gebrim. Breast cancer stage, molecular subtype and survival in patients with obesity: a Brazilian cohort study. [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P3-03-20.

Abstract P3-05-47: Regional Lymph node percutaneous analysis in patients with breast cancer

Background: The evaluation of regional lymph nodes in patients with breast cancer is one of the main predictive and prognostic factors for treatment. The most frequently methods of percutaneous evaluation for suspicious lymph nodes are fine needle aspiration (FNA) and core needle biopsy (CNB). According to the international literature, CNB and FNA are considered diagnostic methods with high specificity (98% vs. 99%), however FNA can present up to 21% of inconclusive results due to insufficient material, which leads to recall and delay in treatment approach. Although CNB is well established as a percutaneous method for the diagnostic evaluation of suspicious breast lesions, the literature is still scarce regarding the use of this method for the evaluation of suspicious regional lymph nodes in patients with breast cancer. Objectives: To analyze the results of percutaneous biopsies performed in suspected lymph nodes according to the topography and the type of needle used, and to verify the preferred method used. Methods: This was a retrospective study evaluating a public Hospital in São Paulo – Brazil (Pérola Byington Hospital database). Patients who underwent ultrasound-guided percutaneous lymph node biopsy from May 2015 to November 2017 were included. Data were analyzed and the type of biopsy (FNA or CNB) and the results were analyzed. Results: 106 medical records of patients with previous breast cancer and that underwent lymph node biopsy were reviewed. The mean age was 54.7 years (SD±12.4) in the CNB group and 54.7 years (SD±10.8) in the FNA group. Most of the patients were submitted to CNB (66% - 71 patients) and 34% were evaluated with FNA (35 patients). According to the topography of the lymph nodes, 80% were in the axilla (n=84), 10% in the supraclavicular region (n=11) and 10% in the cervical region (n=11). When analyzing the FNA results, 31% did not present sufficient material (n=11), 37% were malignant (n=13), 20% were benign (n=7) and 12% showed cellular atypia (n=12). Among the CNB performed in suspected lymph nodes, 53% were malignant (n=38) and 31% were benign (n=33), and no one had insufficient material. There were no reports of complications related to the procedures. In the insufficient material group, 27% (n=3) of the patients underwent a new percutaneous biopsy (2 CNB with malignant result and 1 FNA with inconclusive result) and 73% (8) were maintained in follow-up. The mean follow-up time was 24 months, and clinical and imaging stability was confirmed after this period. In the CNB group with malignant result, 10% (4) were diagnosed with neoplasia of other sites (cervix, lymphoma, melanoma and gastrointestinal), 78% (30) presented immunohistochemistry in agreement with that of the breast, 3% (1) presented different immunohistochemistry and in 9% (3) this evaluation was not performed. Conclusion: CNB was the preferred diagnostic method in our Hospital (66% vs 34%), being considered a viable procedure to evaluate lymph nodes in various topographies and with low rates of inconclusive results. Besides that, immunohistochemistry was done in 91% of the cases showing the importance of this analysis in the treatment of the recurrence or even in the diagnosis of other primary tumors. In the future, studies that assess indirect costs may confirm the applicability of CNB in patients with suspicious lymph nodes in terms of achieving greater agility and resolution.

Citation Format: Marina Diogenes, ANDRE MATTAR, Andressa Amorim, Maria Isabela Caldas Sawada, Luiz Henrique Gebrim, Jorge Shida. Regional Lymph node percutaneous analysis in patients with breast cancer [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P3-05-47.

Abstract P1-04-17: Clinical and pathological differences between HER2 Low and other cancer subtypes in breast cancer patients

Background: HER2 is a tyrosine kinase receptor belonging to the human epidermal receptor family and is considered an important proto-oncogene in the biology of breast carcinoma. HER2 overexpression is determined by a +3 score on the immunohistochemistry (IHC) assay. In addition, tumors with IHC results of +1 or +2 with ISH negative were defined as HER2-low. Recent studies have shown that the clinicopathological characteristics of HER2-low tumors, pointing out potential differences regarding hormone receptor status and new treatment possibilities in this patients. Objective: To assess the frequency and clinicopathological differences between cancer subtypes, as well as the survival of these patients. Methods: All patients with breast cancer diagnosed between 1987 and 2021 included in the Pérola Byington Hospital database were eligible. Patients were excluded if they had bilateral disease, had participated in clinical studies, or had incomplete data. The primary endpoint was overall survival stratified by cancer subtype, secondary endpoints were clinicopathological differences between cancer subtypes and death probability. Both the t-test and the chi-square test were used to analyze the association of each variable between the groups. Multivariate analysis was used to calculate odds ratios (OR) and 95% confidence intervals (CI) for the death outcome. Cox regression was used for survival analysis, with the Log-rank method and the results were presented in a survival graph using the Kaplan-Meier method. The R software version 4.1.1 was used to perform all analyzes, with a p-value &lt; 0.05 being considered statistically significant. Results: 11,234 patients were included: 4,541 (40.42%) had Luminal cancer subtype, 2,955 (26.30%) HER2 Low, 2,242 (19.96%) triple negative, and 1,496 (13.32%) HER2 overexpression. Age, self-reported ethnicity, BMI, presence of comorbidities, clinical stage, nuclear grade, histological grade, family history, radiotherapy, chemotherapy, surgery, local, and systemic recurrence, and death showed statistically significant differences between cancer subtypes (table 1). In the multivariate regression (adjusted for the other evaluated characteristics), patients with HER2 overexpression cancer subtype showed a 44.8% greater probability of death than patients with HER2 Low (OR 1.448, 95%CI 1.046-2.004, p=0.026), while the patient with triple-negative cancer had a 26.1% lower probability of evolving to death when compared to the HER2 Low patient (OR 0.739, 95%CI 0.562-0.969, p=0.0229). The luminal subtype showed no statistically significant difference when compared to the patient with HER2 Low. Overall survival showed a statistically significant difference between cancer subtypes, with a median of 12 years for Luminal HR 0.816 (0.73-0.913), 15 years for HER2 overexpression HR 1.154 (1.003-, 327), and no statistical difference for triple negative HR 0.978 (0.859-1.114) compared to 12 years for HER2 Low. Conclusion: This study in breast cancer patients demonstrates significant differences between cancer subtypes, with a higher probability of progression to death for patients with HER2 overexpression, while patients with Luminal subtype had a lower probability, when compared with HER2 Low. More studies are needed to clarify the impact of these differences between cancer subtypes on response to therapy.

Association between cancer subtype and other variables (n=11,234).

Citation Format: ANDRE MATTAR, Andressa Amorim, Marina Diogenes, Jorge Shida, Luiz Henrique Gebrim. Clinical and pathological differences between HER2 Low and other cancer subtypes in breast cancer patients [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P1-04-17.

Breast cancer treatment: A phased approach to implementation

Optimal treatment outcomes for breast cancer are dependent on a timely diagnosis followed by an organized, multidisciplinary approach to care. However, in many low- and middle-income countries, effective care management pathways can be difficult to follow because of financial constraints, a lack of resources, an insufficiently trained workforce, and/or poor infrastructure. On the basis of prior work by the Breast Health Global Initiative, this article proposes a phased implementation strategy for developing sustainable approaches to enhancing patient care in limited-resource settings by creating roadmaps that are individualized and adapted to the baseline environment. This strategy proposes that, after a situational analysis, implementation phases begin with bolstering palliative care capacity, especially in settings where a late-stage diagnosis is common. This is followed by strengthening the patient pathway, with consideration given to a dynamic balance between centralization of services into centers of excellence to achieve better quality and decentralization of services to increase patient access. The use of resource checklists ensures that comprehensive therapy or palliative care can be delivered safely and effectively. Episodic or continuous monitoring with established process and quality metrics facilitates ongoing assessment, which should drive continual process improvements. A series of case studies provides a snapshot of country experiences with enhancing patient care, including the implementation of national cancer control plans in Kenya, palliative care in Romania, the introduction of a 1-stop clinic for diagnosis in Brazil, the surgical management of breast cancer in India, and the establishment of a women's cancer center in Ghana.

Assessment of IGF-1 expression in the peripheral blood of women with recurrent breast cancer

Breast cancer is the most common malignancy affecting women worldwide. The insulin-like growth factor 1 (IGF-1) gene encodes a protein responsible for a wide variety of physiological processes, including differentiation and cell proliferation. Despite several studies on tumor tissues, no study has evaluated IGF-1 expression in the peripheral blood of women with recurrent breast cancer.In this cross-sectional study, IGF-1 expression in the peripheral blood of 146 women with breast cancer treated approximately 5 years ago was quantified by quantitative reverse transcription polymerase chain. The women were divided into 2 groups: non-recurrence (n = 85) and recurrence (n = 61). Statistical analysis of the data was performed using ANOVA, Mann-Whitney, and Chi-squared tests (P < .05).The results showed no significant difference in IGF-1 expression between the non-recurrence and recurrence groups (P = .988). In the subgroups of patients with lymph node involvement, no statistically significant difference was observed in IGF-1 expression between women with recurrence and those non-recurrence (P = .113). In patients without lymph node metastases, IGF-1 messenger ribonucleic acid (mRNA) expression levels were significantly higher in the non-recurrence group than in the recurrence group (P = .019). Furthermore, using the median IGF-1 mRNA expression as the cutoff point, it was obtained a statistically significant difference in tumor histological grade among women with recurrent breast cancer (P = .042).These data showed significantly higher IGF-1 expression in women without lymph node metastases in the non-recurrence group compared with the recurrence group. In addition, a significant difference was observed in median IGF-1 mRNA expression in relation to tumor histological grade in women with recurrent breast cancer.

CYP19A1 gene expression in the peripheral blood of Brazilian women with breast cancer relapse

Background

The CYP19A1 gene, which encodes the enzyme responsible for androgen aromatization into estrogens, may play an important role in breast cancer aggressiveness. However, no study has evaluated CYP19A1 gene expression in the peripheral blood of women with relapsed breast cancer.

Methods

In this cross-sectional study, CYP19A1 gene expression was quantified by RT-PCR in the peripheral blood of 146 women with breast cancer who were first divided into two groups according to the expression of CYP19A1 (low and high); each group had 73 patients. Subsequently, women were divided into two groups: those without recurrence (control, n = 85) and those with recurrence (study, n = 61). Statistical analysis of the data was performed using ANOVA, the Mann-Whitney, Chi-square or Fisher’s exact test (p <  0.05).

Results

There were no significant differences between the relative expression of CYP19A1 mRNA in the low expression group and the high expression group according to the variables studied. There were no significant differences in CYP19A1 gene expression in the study and control groups (p = 0.8461). In the relapse group, CYP19A1 gene expression was significantly higher in the hybrid luminal subtype than in the triple-negative subtype (p = 0.0321), whereas it was significantly lower in HER2-negative cases than in HER2-positive cases (p <  0.0376). Women with locoregional recurrence showed higher expression than women with distant recurrence (p <  0.0001).

Conclusions

The present study found no significant differences between women with high and low expression of the CYP19A1 gene mRNA or between those in the study group and the control group. However, in women with recurrence, there was increased expression of CYP19A1 mRNA in those who had the luminal hybrid subtype and locoregional relapse and decreased expression in those negative for HER2.

Practice-changing use of 21-gene oncotype DX breast recurrence score assay in a public hospital in Brazil: Results of 155 cases

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Background: The 21-gene assay estimates risk of recurrence expressed as a Recurrence Score result between 0 and 100. The assay is clinically validated to predict chemotherapy (CT) benefit in node-negative (N0) and node-positive (up to three axillary nodes, N1) hormone receptor-positive (HR+) early-stage breast cancer (ESBC). The TAILORx study, which randomized 6711 women with N0 ESBC and Recurrence Score result 11-25 to hormonal therapy (HT) ± CT, demonstrated that patients older than 50 years derived no benefit from CT+HT, although younger patients with Recurrence Score result 16-25 may derive some benefit. The 21-gene assay has been incorporated in practice guidelines worldwide, based on evidence of clinical utility in N0 and N1 ESBC. We evaluated the impact of the 21-gene test on treatment decisions for patients with N0 and N1 ESBC at Sistema Único de Saúde in Brazil. Methods: Eligible patients were post-surgery with T1/T2 tumors, had HR+, HER2−, N0 or N1 ESBC, and were candidates for adjuvant systemic therapy. Treatment recommendations, CT+HT or HT alone, were captured before and after 21-gene test results. All patients were seen at Pérola Byington Hospital, a public hospital in São Paulo, Brazil. TAILORx results were used to guide decisions for or against CT for each patient. Results: From 08/2018 to 04/2019, 155 women were enrolled. Patient mean age was 57.6 years (29-78), 116 (75%) were postmenopausal, and 53 (34%) had N1 breast cancer. Based on clinical data alone, 151 patients had pre-assay recommendations of CT. Post-assay, 106 of 151 patients (70%) had changes in CT recommendation: 104 (69%) initially recommended CT received HT alone, and 2 (1%) initially recommended HT alone received CT+HT (Table). Using the modified Adjuvant!Online criteria for clinical risk classification, 109 of 155 patients (70%) had high risk, 48 (44%) of whom received CT. Of 46 patients with low clinical risk, 10 (22%) received CT. CT use trended with histologic grade: 11% with grade 1, 69% with grade 2, and 61% with grade 3. Most of our patients had tumor bigger than 2 cm (61%) with 8% bigger than 4 cm. Conclusions: The change in clinical practice at this public hospital was greater than expected: 69% of initial treatment recommendations were changed with the Recurrence Score result to omit CT. Clinicopathologic criteria did not correlate well with Recurrence Score results and did not identify those most likely to benefit from CT. A cost-effectiveness study is underway at our institution. [Table: see text]

Overview of obesity and breast cancer in Brazil: 24 year of follow up

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Background: Obesity is one of the major public health challenges of the 21st century. The prevalence of obesity is growing exponentially across all age groups and on all continents and it is associated with morbidities such as cardiovascular disease, diabetes mellitus type 2, dyslipidemia, hypertension and cancer. There is a higher risk of developing breast cancer in postmenopausal obese women, and with worse outcome for women of all ages. Objectives: To evaluate obesity prevalence in breast cancer patients and its association with recovering, survival, death, age, Human Epidermal Growth Factor Receptor 2 (HER2) and anti-human KI67 antibody(KI67). Methods: A retrospective cohort study was performed between 1994 and 2018 at the Breast Cancer Department, São Paulo State Government Women's Health Reference Center (Perola Byington Hospital), São Paulo, Brazil with 8824 breast cancer patients. From those, 2899 patients were excluded because they did not have description of weight and/or Body Mass Index (BMI). Survival analysis was performed according to BMI groups. Results: The participants had mean (SD) age of 54 (12.0) years and weight of 70 (15.0) kg. There were 769 (13%) deaths and the mean survival was 20 (2.0) years. 1787 (30%) participants were stratified in obese (BMI≥30Kg/m2) and 4138 (70%) non-obese Obese were older (p < 0,001) and had a higher frequency of HER2 negative (p < 0,04) than non-obese women. There were not a significant difference in frequencies of KI67, recovering and survival between groups. The prevalence of obesity was not different over 24 years. Conclusions: There was a relevant prevalence of obesity in breast cancer patients, which was associated with HER2 negative and age, but not with recovering or survival.

Prognostic factors impacting survival in early HER2-positive breast cancer (BC): Results from a 1,142 patients database study

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Background: early systemic therapy has reduced recurrence and mortality from BC, especially among HER2+ subtype. Despite these advances, the difficulty of developing countries in incorporating new treatments, as well as the molecular and phenotypic profiles of HER2+ BC, are associated with the heterogeneity of treatment responses, leading to poor prognosis and outcomes. However, real-world data on prognostic factors for early HER2+ BC patients are scarce, especially in the Brazilian context. Therefore, this study aims to evaluate the influence of prognostic factors on disease-free survival (DFS) and overall survival (OS) in early HER2+ BC patients. Methods: this retrospective study identified early HER2+ BC (stage I to III with positive immunohistochemistry and in-situ hybridization) patients from Pérola Byington’s public hospital database (São Paulo, Brazil) diagnosed between January 2010 to March 2018. Patients were excluded if they were less than 18 years old, participated in clinical trials, presented metastatic disease de novo, concurrent malignancy, or inconsistent data. Multivariate Cox regression was used to evaluate prognostic factors for survival, and OS and DFS were estimated by Kaplan-Meier analyses. Results: of the 1,625 patients identified in the database, 1,142 women were included in the study. Of those, 40% were diagnosed with less than 50 years old. Among the included patients, 40.3% were HR-/HER2+ and 59.7% were HR+/HER2+. In addition, 19.4% of patients were diagnosed at stage I, 42.9% at stage II and 37.7% at stage III. A total of 1033 patients were included in the DFS analysis, with a probability of 71.8% DFS in 5-years. For OS analysis, a probability of 75.4% OS in 5-years was observed for 1139 patients included. The multivariate analysis showed that tumor staging, lymph node involvement and pathological complete response (pCR) were independent prognostic factors for both DFS and OS. Conclusions: the study in the Brazilian cohort corroborates the literature, showing that tumor staging, pCR, and lymph node involvement are key markers for DFS and OS and they should be considered when managing the early HER2+ BC patients. [Table: see text]

Economic evaluation of the oncotype DX test for hormone receptor positive (HR+) early-stage breast cancer (BC) from the Brazilian societal perspective

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Background: Selecting appropriate patients for AC (adjuvant chemotherapy) remains an important issue in BC treatment. Although AC improves clinical outcomes toxicity and economic burden is substantial. The Oncotype DX test identifies high-risk patients likely to benefit from AC who otherwise might not be identified through standard parameters (SP), and low-risk patients unlikely to benefit from AC, avoiding toxicities and inherent risks. This study estimated the incremental cost-effectiveness ratio and budget impact (BI) of Oncotype DX testing from the perspective of the Brazilian Public Health System. Methods: A Markov transitional state model was developed with 3 states: recurrence free, distant recurrence, and death. The model compared the scenario in which patients are screened by SP with a proposed scenario with Oncotype DX testing. Changes in therapeutic recommendations and cost of treatment were obtained from a prospective clinical survey at Pérola Byington Hospital. Additional data was obtained from literature. As a societal perspective analysis, medical costs (test, AC, and adverse events), costs of productivity loss, transportation and employment leave were considered. Population was estimated from BC incidence, proportion of early stage cases, and HR expression. An incremental proportion of 10% per year of patients using Oncotype DX testing was assumed. BI analysis had a 5-year horizon and cost-effectiveness a lifetime horizon (5% annual discount). Results: Oncotype DX results as identifier of a subgroup at higher risk of relapse and greater benefit with AC was dominant over SP. Oncotype DX testing resulted in clinical benefits in terms of life-years gained (0.62) and quality-adjusted life years (0.54), related to lower incidence of distant recurrence and use of AC, both of which greatly impacted quality of life. Testing resulted in economic benefits, with lower average cost per patient (−BRL 3,855). Incorporation of Oncotype DX testing resulted in potential savings reaching BRL 107 million in the 5th year stemming from the decrease in AC and consequent decrease in indirect costs. Conclusions: Patients with HR+, HER2− early stage BC may present different risks of relapse and likelihoods of benefiting from AC. With high clinical impact for patients and high economic impact for the health system, a tool that safely and accurately identifies the subgroup of patients who really needs AC is essential. Oncotype DX test incorporation in the Brazilian Public Health System should be considered.

Expression of matrix metalloproteinase 2 and 9 in breast cancer and breast fibroadenoma: a randomized, double-blind study

Background

Matrix metalloproteinases (MMPs) 2 and 9 may play an important role in cell proliferation and dissemination of cancer. However, few studies have compared the expression of these proteins between breast cancer and fibroadenoma.

Material and methods

A randomized, double-blind study was carried out in 66 premenopausal women, aged 20-49 years, who had been diagnosed with fibroadenoma or breast cancer. The patients were divided into two groups: Group A, control (fibroadenoma, n=36) and Group B, study (cancer, n=30). Immunohistochemical analysis was performed using tissue samples of fibroadenoma and breast cancer to assess MMP-2 and MMP-9 antigen expression. Cells were considered positive if exhibiting brown cytoplasmic staining. Fisher’s exact test was used to compare the percentage of cases with cells expressing MMP-2 and MMP-9 in control and study groups (p < 0.05).

Results

Light microscopy showed a higher concentration of cells with positive cytoplasmic staining for MMP-2 and MMP-9 expression in breast cancer than in fibroadenoma. The percentage of cases with cells expressing MMP-2 in the control and study groups was 41.67% and 86.11%, respectively (p < 0.0009), whereas the percentage of cases with cells expressing MMP-9 in groups A and B was 66.67% and 93.33%, respectively (p<0.0138). MMP-2 and MMP-9 positive expression was significantly higher in moderately differentiated tumors compared to well and poorly differentiated tumors, p <0.005 and p<0.001, respectively.

Conclusions

The current study shows that MMP-2 and MMP-9 protein expression was significantly higher in the breast cancer than in the fibroadenoma and also in moderately differentiated breast cancer.

Abstract P3-04-01: The value of stereotactic vacuum-assisted biopsy in the investigation of microcalcifications in 1354 patients in public Brazilian hospital

Background: The gold standard for breast biopsy procedures is currently an open excision of the suspected lesion. However, an excisional biopsy inevitably makes a scar. The cost and morbidity associated with this procedure has prompted many physicians to evaluate less invasive, alternative procedures. More recently, image-guided percutaneous core-needle biopsy has become a frequently used method for diagnosing palpable and non-palpable breast lesions. Although sensitivity rates for core-needle biopsy are high, it has the disadvantage of histological underestimation, which renders the management of atypical ductal hyperplasia, papillary lesions, and fibroepithelial lesions somewhat difficult. Stereotactic vacuum assisted breast biopsy (VABB) was developed to overcome some of these negative aspects of core-needle biopsy. VABB allows for a sufficient specimen to be obtained with a single insertion and can provide a more accurate diagnosis and completely remove the lesion under real-time ultrasonic guidance. The advantage of complete lesion removal with VABB is to reduce or eliminate sampling error, to decrease the likelihood of a histological underestimation, to decrease imaging-histological discordance, to decrease the re-biopsy rate, and to diminish the likelihood of subsequent growth on follow-up, especially when stereotactic VABB is used to investigate microcalcifications. This method is expensive but cost effective when used to investigate microcalcifications classified as BI-RADS 4 and 5.

Methodology: We performed a review in 1,354 patients with suspicious mammography microcalcifications, classified as BI-RADS 4 or 5 that were seen in Perola Byington Hospital from July 2012 to July 2017 in São Paulo-Brazil. We have used aHologic Lorad Multicare Platinum Stereotactic Prone Breast Biopsy and a Surus Pearl (Hologic, Malbolrough, Massachusetts, USA), with gauge 9 probe. Four to eight fragments (median of 6) were obtained with the placement of a metal clip in the bed that the biopsy was performed, and histopathological analysis was made.

Results:The histopathological study of the lesions revealed benign alterations in 956 (68%) of our patients. The findings were positive for malignancy in 358 patients (29%) and the precursor lesions were diagnosed in 40 (3%). In 81 cases (5.9%) the findings were discordant. The sensitivity of the method was 84.4%, specificity was 96.1%, false negative rate was 4.5%, positive predictive value (PPV) was 89.8%, negative predictive value (NPV) was 93.8%. In literature review the sensitivity varies 91.5-100%, specificity 81.9-110%, false negative rate 0-3.3%, PPV 92.2-100% and NPV 80.5-99.5%. All patients with positive or discordant cases underwent surgical treatment to increase the margin or complete removal of the lesion. Conclusions: The VABB is an outpatient procedure that avoids hospital admissions for diagnostic elucidation in most of cases suspected of malignancy. It has high predictive value in both benign and malignant lesions, guiding therapeutic planning. In addition to presenting the cost lower than the surgical biopsy it indirect increases the supply of hospital beds for cancer treatment.

Citation Format: Mattar A, Amorim AG, Ramos MdNM, Shida JY, Fonseca GR, Hegg R, Gebrim LH. The value of stereotactic vacuum-assisted biopsy in the investigation of microcalcifications in 1354 patients in public Brazilian hospital [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P3-04-01.

Specific protocols of controlled ovarian stimulation for oocyte cryopreservation in breast cancer patients

Background

Fertility preservation is an important concern in breast cancer patients. In the present investigation, we set out to create a specific protocol of controlled ovarian stimulation (cos) for oocyte cryopreservation in breast cancer patients.

Methods

From November 2014 to December 2016, 109 patients were studied. The patients were assigned to a specific random-start ovarian stimulation protocol for oocyte cryopreservation. The endpoints were the numbers of oocytes retrieved and of mature oocytes cryopreserved, the total number of days of ovarian stimulation, the total dose of gonadotropin administered, and the estradiol level on the day of the trigger.

Results

Mean age in this cohort was 31.27 ± 4.23 years. The average duration of cos was 10.0 ± 1.39 days. The mean number of oocytes collected was 11.62 ± 7.96 and the mean number of vitrified oocytes was 9.60 ± 6.87. The mean estradiol concentration on triggering day was 706.30 ± 450.48 pg/mL, and the mean dose of gonadotropins administered was 2610.00 ± 716.51 IU. When comparing outcomes by phase of the cycle in which cos was commenced, we observed no significant differences in the numbers of oocytes collected and vitrified, the length of ovarian stimulation, and the estradiol level on trigger day. The total dose of follicle-stimulating hormone and human menopausal gonadotropin administered was statistically greater in the group starting cos in the luteal phase than in the group starting in the late follicular phase.

Conclusions

Our results suggest that using a specific protocol with random-start ovarian stimulation for oocyte cryopreservation in breast cancer patients is effective and could be offered to young women undergoing oncologic treatment.

Comparative study between ultrasound-guided fine needle aspiration cytology of axillary lymph nodes and sentinel lymph node histopathology in early-stage breast cancer

The replacement of sentinel lymph node biopsy (SNB) by ultrasound-guided fine-needle aspiration (US-guided FNA) cytology of axillary lymph nodes is controversial, despite the simplicity and reduced cost of the latter. In the present study, US-guided FNA was performed in 27 patients with early-stage breast cancer for comparison with SNB. Data were analyzed by calculation of sample proportions. Tumor subtypes included invasive ductal carcinoma (85%), invasive lobular carcinoma (7%), and tubular and metaplastic carcinoma (4%). FNA had a sensitivity of 45%, specificity of 100%, positive predictive value of 100% and a negative predictive value of 73%. Axillary lymph node cytology obtained by US guided-FNA in patients with breast cancer had a specificity similar to that of sentinel lymph node histopathology in the presence of axillary node metastases. However, when lymph node cytology is negative, it does not exclude the existence of metastatic implants, due to its low sensitivity in comparison to sentinel lymph node histopathology.

A rare case of severe myositis as paraneoplastic syndrome on breast cancer

BACKGROUND

Dermatomyositis and polymyositis are both types of idiopathic inflammatory myositis characterized by inflammation and weakness of proximal skeletal muscles and skin rash.

CASE

A 49-year-old Caucasian woman recently diagnosed with breast cancer classified as T1N2M0, stage IIIA, presenting skin rash associated with heliotrope and Gottron's papules. In addition, there was a progression to a severe reduction in proximal muscle strength with severe dysphagia. The initial treatment was conducted, and the patient recovered from all symptoms and followed adjuvant cancer management.

TREATMENT

At first, high dose of corticosteroid was administered as pulse therapy, and a radical mastectomy was indicated due to the severe symptoms of the paraneoplastic syndrome. Then chemotherapy and radiotherapy were applied, and oral corticoid associated with immunosupressive drug was administered for dermatomyositis control.

DISCUSSION

The association between myositis and an increased risk of cancer has been demonstrated over the years. This patient has a high probability of dermatomyositis diagnosis. The initial treatment with high dose of glucocorticoids may result in an improvement of muscle lesions. Second-line treatment with azathioprine, methotrexate, or cyclophosphamide may be required for aggressive disease. Removal of the cancer induces improvement of paraneoplastic syndrome.

CONCLUSION

Dermatomyositis can be a clinical manifestation of a paraneoplastic syndrome in patients with breast cancer. It is a rare diagnosis, and there is little evidence to guide treatment until now. It is possible to control the evolution of dermatomyositis with high doses of glucocorticoids in almost all cases; however, in severe cases of paraneoplastic syndrome, cancer treatment should start immediately.

Abstract P5-09-15: Polymorphism of the CYP2D6 gene in Brazilian women with breast cancer treated with tamoxifen

The prodrug tamoxifen is the standard endocrine treatment for estrogen receptor-positive breast cancer. Its effect depends on activation by the CYP2D6 enzyme, which is encoded by a highly polymorphic gene that varies according to ethnicity. The most important polymorphic variants are *4 (abolished enzyme activity), *10 and *17 (decreased enzyme activity) found in 25%, 38-70% and 35% of Caucasians, Asians and Africans, respectively, resulting in low endoxifen levels (a major metabolite), a lack of response to tamoxifen and a poor prognosis. There is a widespread racial miscegenation in Brazil and the country's public health care system has made tamoxifen available and free of charge to all women with hormone-sensitive breast tumor despite the undetermined genetic profile of these patients.This study aims to evaluate polymorphism frequency of the CYP2D6*4, *10 and *17 alleles in Brazilian breast cancer patients under tamoxifen treatment and metabolism phenotype. Methods: The study was approved by the Internal Review Board of the Federal University of Piauí. All patients signed an informed consent term before study entry. Sixty-five women with estrogen and progesterone receptor-positive and Her-2 negative breast carcinomas were enrolled in the study. A 3-ml peripheral blood sample was collected from each patient, using specific polymerase chain reaction technique (PCR) to analyze haplotypes *1, *4, *10 and *17, determined by studies of different Single-Nucleotide Polymorphism (SNP). Microsoft Office Excel software 2010 was used to compile and analyze the data obtained. Results: The frequency of CYP2D6 alleles *4, *10 and *17 was 17%, 37% and 3%, respectively. Haplotype *1/*10 was present in 26%, while the phenotype of intermediate metabolism occurred in 12% of the women studied. Conclusion: The present study showed a polymorphism frequency of CYP2D6, mainly of allele *10 and a deficiency in tamoxifen metabolism, characterized by intermediate metabolism in 12% of the women studied. Nevertheless, further studies must be developed with a larger sample of women to study not only the presence of the polymorphic variant but also disease prognosis.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P5-09-15.

Estrogen receptor alpha/beta ratio and estrogen receptor beta as predictors of endocrine therapy responsiveness-a randomized neoadjuvant trial comparison between anastrozole and tamoxifen for the treatment of postmenopausal breast cancer

BACKGROUND

The role of estrogen receptor beta (ER-β) in breast cancer (BC) remains unclear. Some studies have suggested that ER-β may oppose the actions of estrogen receptor alpha (ER-α), and clinical evidence has indicated that the loss of ER-β expression is associated with a poor prognosis and resistance to endocrine therapy. The objective of the present study was to determine the role of ER-β and the ER-α/ER-β ratio in predicting the response to endocrine therapy and whether different regimens have any effect on ER-β expression levels.

METHODS

Ninety postmenopausal patients with primary BC were recruited for a short-term double-blinded randomized prospective controlled study. To determine tumor cell proliferation, we measured the expression of Ki67 in tumor biopsy samples taken before and after 26 days of treatment with anastrozole 1 mg/day (N = 25), tamoxifen 20 mg/day (N = 24) or placebo (N = 29) of 78 participants. The pre- and post-samples were placed in tissue microarray blocks and submitted for immunohistochemical assay. Biomarker statuses (ER-β, ER-α and Ki67) were obtained by comparing each immunohistochemical evaluation of the pre- and post-surgery samples using the semi-quantitative Allred's method. Statistical analyses were performed using an ANOVA and Spearman's correlation coefficient tests, with significance at p ≤ 0.05.

RESULTS

The frequency of ER-β expression did not change after treatment (p = 0.33). There were no significant changes in Ki67 levels in ER-β-negative cases (p = 0.45), but in the ER-β-positive cases, the anastrozole (p = 0.01) and tamoxifen groups (p = 0.04) presented a significant reduction in post-treatment Ki67 scores. There was a weak but positive correlation between the ER-α and ER-β expression levels. Only patients with an ER-α/ER-β expression ratio between 1 and 1.5 demonstrated significant differences in Ki67 levels after treatment with anastrozole (p = 0.005) and tamoxifen (p = 0.026).

CONCLUSIONS

Our results provide additional data that indicate that the measurement of ER-β in BC patients may help predict tamoxifen and anastrozole responsiveness in the neoadjuvant setting. These effects of hormonal treatment appear to be dependent on the ratio of ER-α/ER-β expression.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN89801719.

Abstract P2-05-17: Correlation between cyclin D1, estrogen and progesterone receptors in invasive breast cancer after short-term treatment with tamoxifen or anastrozole

INTRODUCTION: Hormone therapy is associated with reduced breast cancer mortality. The use of biomarkers that are predictive of early cellular responses has been explored as a predictor of hormone resistance. Estrogen and progesterone receptor positivity and cyclin D1 have been associated with resistance to treatment with tamoxifen.

OBJECTIVES: The aim of this study was to investigate the variations in the levels of cyclin D1 and the estrogen and progesterone receptors (ER and PR, respectively) in postmenopausal patients with ER− or PR-positive breast cancer after short-term treatment (26 days) with tamoxifen, anastrozole or a placebo.

METHODS: This was a prospective, randomized double-blind study conducted in 71 patients with infiltrating ductal carcinoma (stages II and III) receiving care at either Pérola Byington Hospital or São Paulo Hospital (São Paulo, Brazil). The patients were divided into three groups based on their treatment during the preoperative period (26 days): P (placebo, N = 26), T (tamoxifen, 20 mg/day, N = 22) and A (anastrozole, 1 mg/day, N = 23). The biopsies were performed at diagnosis and after mastectomy (26th day), and the tumors were isolated by tissue microarray. Immunohistochemistry was performed using anti-cyclin D1 (Novocastra DCS-6), anti-ER (Dako-M7047) and anti-PR (Dako-M3569) antibodies. The semiquantitative analyses were performed using Allred criteria, and the statistical analyses were performed with the ANOVA parametric test (p ≤ 0.05).

RESULTS: A reduction in the mean PR level from 4.22 (pre-treatment) to 1.94 (post-treatment) was observed only in patients treated with anastrozole (p = 0.01). A positive linear correlation between cyclin D1 and PR levels was observed in group A (p = 0.0001), whereas group T exhibited a negative correlation (p = 0.0001). No correlation was observed in group P (p = 0.35).

CONCLUSION: PR and cyclin D1 are likely predictive of an early response to aromatase inhibitors in breast cancer.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P2-05-17.

P3-07-37: Clinical Characteristics and Treatment of Brazilian Women with Breast Cancer at Public and Private Institutions

Background: Breast cancer is the most common type of cancer among Brazilian women with almost 50.000 new cases per year. There are few data regarding the clinical presentation, treatment and specially outcome of this population. Brazilian health system is composed by Public institutions (Pu); Private centers (Pr) and some institutions that assist both Public and Private patients (PuPr).

Material and Methods: We collected data from 17 cancer centers distributed throughout Brazil among Pu; Pr and PuPr centers. We've analyzed data from 1-clinical characteristics, 2- pathologic characteristics and 3-type of treatment received among 2435 patients from May 2008 to May 2009.

Results: Mean age at diagnosis was 53 years, with about 30% below age 50. Most of the cases were Invasive Ductal Cancer (83%). Stage 0 was seen in 3.2%, Stage I in 21,8%, Stage II in 46,6%, Stage 3 in 24,6% and Stage IV in 3,9 %. Clinical Stage III + IV was seen in 18,5% of the Pu institutions, only 3,7% of the Pr ones and about 6,2% among those PuPr. Hormone receptors were positive in 55%. Her-2 was overexpressed in 27,3% of the patients, and triple negative were seen in 11,6%. Most of the patients were submitted to surgery (92,9%). In Pu institutions only 36% of the patients were submitted to Breast Conserving Surgery (BCS) and in the Pr institutions 49,4% of the patients were submitted to BCS and in the PuPr 47%. Breast reconstruction was made in 15,8% and did not differ between Pu and Pr institutions. Sentinel node biopsy was done in 30,6% of the patients (26,8% of the patients from the Pr institutions and 26,8% of the Pu ones and 33% among PuPr). Neoadjuvant treatment was done in 21,5% of the patients (Pu=27,2%; Pr=13,9% and PuPr 13,2%). Most of this neoadjuvant treatment was chemotherapy (93,8%) and only 4,3% was hormonetherapy (HT). 30% of the patients received AC, 41% A+taxane and 18,9% FAC/FEC. Besides we have almost 30% of Her-2 overexpressed only 1,1% of the patients received trastuzumab in the neoadjuvant setting. Tamoxifen was used in 48,3% when neoadjuvant HT was done, and aromatase inhibitor (AI) was used in 34,5%. Most of the patients received any kind of adjuvant treatment (89,2%). Chemotherapy was done in 76,6% and hormonetherapy in 69,8%. When chemotherapy was used the preference regiment was FAC/FEC (27,3%), followed by CMF (17,5%) and AC (11,9%). Trastuzumab was use in only 5,8% of the patients (Pu=6,8%, Pr=18,3% and PuPr 3% among all patients that received chemotherapy). In the adjuvant setting, Tamoxifen (TAM) was prescribed in 69,8% of the cases (Pu=87,6%, Pr=79,6% and PuPr 78,8%), AI in 8,2% (Pu=5,9%, Pr=9,3% and PuPr 13,8%), and sequential TAM/AI in 6,6% (Pu=6,1%, Pr=8,3% and PuPr 6,4%). About 17% of the patients had metastasis.

Conclusions: There are important differences between the public and private institutions in Brazil, the patients from the Pu institutions were five times more likely to be diagnosed in stage III or IV, they usually receive neoadjuvant treatment, and when surgery was done, most of them were treated with radical procedures. Besides the overexpression of Her-2 (30%) a minority of the patients received treatment with trastuzumab even for the Private centers (high cost for a developing country).

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P3-07-37.

P5-07-06: Effect of Angiotensin-(1-7) and Angiotensin II on T47D Breast Cancer Cells in the Proliferation and cAMP Production

Angiotensin-(1-7) [Ang(1-7)] is a peptide hormone that produces opposite responses to those of the well-characterized peptide angiotensin II (Ang II). The main actions of Ang(1-7) and AII occur, respectively, via MAS and Angiotensin type 1 receptor (AT1R), respectively. Ang (1-7) has blood pressure and proliferative effects contrary to those of AngII, exhibits significant antiangiogenic activity and may be a novel therapeutic agent for lung cancer treatment targeting a specific AT(1-7) receptor (Soto-Pantoja et al., 2009). Here, our aim was to evaluate T47D breast cancer cell proliferation and cAMP production after treatment with Ang (1-7) and AngII.By means of the cyclic AMP (cAMP) competitive enzymeimmunoassay system we measured cAMP content of T47D cells. Cell proliferation was measured using incorporation of BrdU after Ang (1-7) and AII stimulation. Intracellular cAMP increasing drugs like Forskolin (FK) and isobutylmethylxanthine (IBMX) were also used to stimulate T47D cells.AII inhibited cAMP production (−39%) and A-(1-7) increased its formation (48%). Pattern of cAMP production was not altered when cells were previously incubated with FK. Results were inverted after IBMX incubation. In proliferation, opposite responses were observed for Ang II and Ang (1-7), that is, increasing (7.6 times) and decreasing (7.5 times) proliferation rates respectively. Also both peptides decreased proliferation when cells were stimulated by FK. Exactly the opposite happened after IBMX stimulation, both peptides increased proliferation. These results suggest that Ang (1-7) inhibits growth of T47D cells probably through inhibition of the via RAS/RAF/MAP quinase, what corroboraties previous findings. On the other hand, AngII can induce cell proliferation by an alternative via (CREB/growth factor). Therefore, Ang (1-7) seems to be not only a promising target to develop novel lung cancer therapeutic drugs, but it also might help to prevent the molecular changes that lead the normal breast epithelial cells to cancer initiation.

Financial Support: FAPESP.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P5-07-06.

A case report of male breast cancer in a very young patient: what is changing?

Male breast cancer accounts for 1% of all breast cancer cases, and men tend to be diagnosed at an older age than women (mean age is about 67 years). Several risk factors have been identified, such as genetic and hormonal abnormalities. The present study reported the case of a 25-year-old man who was diagnosed with an advanced invasive ductal carcinoma; however, he did not have any important risk factors. Even though more data is emerging about this disease, more efforts to understand risk factors, treatment options and survival benefits are needed. In this case, we discussed the risk factors as well as the impaired fertility associated with breast cancer therapies.

Short-term anastrozole therapy reduces Ki-67 and progesterone receptor expression in invasive breast cancer: a prospective, placebo-controlled, double-blind trial

PURPOSE

The objective of this study was to compare Ki-67, Bcl-2, Bax, Bak, ER, and PgR expression in postmenopausal women with ER-positive invasive breast cancer (IBC) before and after short-term hormone therapy (HT) with either tamoxifen or anastrozole in order to identify a possible biomarker profile associated with hormone resistance.

METHODS

Fifty-eight patients with palpable IBC were assigned to receive neoadjuvant therapy with either anastrozole, placebo, or tamoxifen for 26 days prior to surgery. Tissue microarray blocks were constructed from pre- and post-treatment biopsy samples and used for immunohistochemical analysis. Biomarker (Ki-67, Bcl-2, Bax, Bak, ER, and PgR) levels were assessed semiquantitatively using the Allred score. A statistical analysis was performed using general estimating equations (GEE) and analysis of variance (ANOVA) with a significance level of 0.05.

RESULTS

There was a significant reduction in PgR scores from baseline (mean, 4.22) to post-treatment (mean, 1.94) in the anastrozole group, but only a non-significant trend toward an increase in PgR scores was found in the tamoxifen group. There was a significant reduction in Ki-67 scores from baseline (mean, 3.61) to post-treatment (mean, 2.56) in the anastrozole group (P = 0.01), but only a non-significant trend toward a reduction in Ki-67 scores was found in the tamoxifen group.

CONCLUSIONS

There was a significant reduction in PgR and Ki-67 expression in the group treated with anastrozole. In the present study, the short-term HT was not associated with changes in apoptosis-related protein levels, regardless the type of drug used.

Retinal function in patients treated with tamoxifen

Tamoxifen, an effective treatment of breast cancer, has been shown to cause ocular toxic effects. The purpose of this study was to determine retinal toxicity by full-field and focal electroretinograms (ERGs) in patients treated with tamoxifen. Fullfield and focal ERGs were obtained from three groups: Tamoxifen-14 females (47-72 years, mean 58.3 + or - 9.1) with normal fundus, treated with tamoxifen from 2 to 37 months; No Treatment-10 females (39-65 years, mean 50.1 + or - 8.7) with previous breast cancer diagnosis and before tamoxifen treatment; Control-13 normal female volunteers (41-81 years, mean 52.7 + or - 12.1). Peak-to-peak amplitude and b-wave implicit time were measured and statistically analyzed.Mean peak-to-peak amplitudes and implicit time from full-field and focal ERGs were comparable for the three different groups. Low-dosage tamoxifen showed no retinotoxic effect assessed by full-field and focal ERG in this small group of women with breast cancer.

Immunohistochemical expression of E-cadherin in sclerosing adenosis, ductal carcinoma in situ and invasive ductal carcinoma of the breast

E-cadherin (EC) is an important glycoprotein cell-adhesion molecule that appears to play a significant role in the progression of breast lesions. The objective of this study was to evaluate EC expression in sclerosing adenosis, ductal carcinoma in situ and invasive ductal carcinoma. Samples of breast lesions from 44 women were used in this study, comprising cases of sclerosing adenosis (n = 11), ductal carcinoma in situ (DCIS) (n = 10) and invasive ductal carcinoma (n = 23). Immunohistochemical evaluation of EC expression was assessed semiquantitatively and considered negative (<10% of cells with stained cytoplasmic membranes), positive+ (10-50% of cells stained) or positive++ (> 50% of cells stained). Fisher's exact test was used to compare the distribution of staining intensity in the lesions (P< 0.05). There was a progressive loss of EC expression from benign to malignant lesions. This difference was statistically significant when sclerosing adenosis was compared with DCIS (P < 0.0002), when sclerosing adenosis was compared with invasive ductal carcinoma (P < 0.008) and when DCIS was compared with invasive ductal carcinoma (P < 0.007). The present findings point to a significant association between reduced EC expression and the progression and aggressivity of breast lesions. Diagn. Cytopathol. 2010. (c) 2009 Wiley-Liss, Inc.

Factors associated with hernia and bulge formation at the donor site of the pedicled TRAM flap

The purpose of this study was to evaluate the correlation between risk factors and hernia or bulge formation at the donor site of the transverse rectus abdominis myocutaneous (TRAM) flap. A retrospective study was conducted between September 2005 and December 2008 in 206 patients who underwent breast reconstruction with pedicled TRAM flap. Eight (3.9%) of these patients had abdominal wall hernia and 26 (12.6%) had abdominal bulging. The incidence of hernia was significantly higher (P < 0.05) among patients with body mass index (BMI) >/= 30 kg/m(2) (hernia incidence, 15.0%) than that among patients with BMI <30 kg/m(2) (hernia incidence, 3.2%), while the incidence of abdominal bulge was significantly lower (P < 0.05) among patients with BMI >/= 30 kg/m(2) (abdominal bulge incidence, 5.0%) than that among patients with BMI >/= 30 kg/m(2) (abdominal bulge incidence, 19.1%). Therefore, obesity was identified as a risk factor for abdominal wall hernia. It was also found that the use of mesh to reinforce the abdominal wall significantly reduced (P < 0.025) the incidence of hernia (use of mesh (hernia incidence, 2.5%) versus non-mesh (hernia incidence, 5.9%)) and abdominal bulge (use of mesh (abdominal bulge incidence, 9.9%) versus non-mesh (abdominal bulge incidence, 17.3%)) among the patients.

Effects of short-time tamoxifen therapy on breast cancer apoptosis and cell cycle regulators

Abstract #3017

Background: Tamoxifen is the most used endocrine therapy in patients with estrogen and/or progesterone positive receptors breast cancer. Tamoxifen acts in a complex manner as estrogen antagonists in tumor tissue, and its interaction with growth factors may lead to inhibition of cell proliferation.&#x2028; Objectives: The aim of this study was to evaluate the expression of estrogen receptor (ER), progesterone receptor (PR), COX-2, Ciclyn D-1, Bcl-2, BAK, BAX and nitric oxide synthase (NOS I, II and III) in breast carcinoma cells using immunohistochemical essay on tumor samples before and after short-time (14 days) exposure to tamoxifen.&#x2028; Material and Methods: A randomized double-blind study was performed with 29 stage II and III breast cancer patients divided according to the following groups: Group C (n= 15 / control) and Group T (n=14 / 20mg of TAM/day for 14 days). Immunohistochemical expression of ER, PR, COX-2, Ciclyn D-1, Bcl-2, BAK, BAX and NOS I, II and III were evaluated before (diagnosis biopsy) and after treatment. The results were classified according Allred score (semi quantitative), based on the intensity and fraction marked cells. The scores of each reaction were compared pre and post treatment, and also to the control group.&#x2028; Results: The mean scores of each reaction before and after treatment for Group T and Group C are seen in the table 1.&#x2028; &#x2028; No significant difference was observed with short-time tamoxifen therapy (table 2 - Mann Whitney test).&#x2028; &#x2028; Discussion: Although tamoxifen has been in clinical use for over 30 years in oncology, its complex manner of action is not totally elucidated. Our results did not show a significant change in breast cancer apoptosis and cell cycle regulators, but bring new data about the short-time exposure to tamoxifen.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 3017.

Study of p53 codon 72 polymorphism in patients with breast cancer

Breast cancer is a common disease in Western societies, with an incidence of 46.31/100,000 women/year in Brazil. The tumor suppressor gene TP53 is one of the most studied genes regarding the presence of mutations. Indeed, 50% of all tumors are known to exhibit changes in the TP53 nucleotide sequence due to carcinogenic processes. As to the presence of polymorphism, the TP53 gene is polymorphic at the nucleotide residue 347 (codon 72). In the current study, we examine if this polymorphism is associated with the clinicopathological parameters of breast cancer patients in a Brazilian population. One hundred and thirteen patients with breast cancer were included. The polymorphic region of the TP53 gene was PCR-amplified from genomic DNA obtained from buccal cells. Specific primers for the Pro and Arg allele were used. Correlations of polymorphism with age, staging, nuclear grade, lymph node status, estrogen receptor status and lymphatic and/or blood vessel invasion were evaluated. Statistical analysis was performed using the Fisher's exact test. The frequency of p53 Arg/Arg was 57% and of the heterozygous allele Arg/Pro it was 39%. There was no correlation between polymorphism and clinicopathological parameters. According to our results, the TP53 polymorphism, at the 347 residue, is not associated with any clinicopathological findings of patients with breast cancer.

Epirrubicina no tratamento do câncer de mama

A epirrubicina, um análogo estrutural da doxorrubicina, pode ser empregada nas várias fases do tratamento quimioterápico do câncer de mama. A epirrubicina possui a vantagem de causar menor toxicidade cardíaca do que a doxorrubicina, quando são comparadas doses habitualmente consideradas como semelhantes do ponto de vista de eficácia. Apesar disso, ainda não está completamente estabelecida a equivalência de dose entre as duas antraciclinas. Os estudos em doenças localizada ou metastática sugerem que ambas podem ser empregadas de maneira intercambiável. Nos tratamentos curativo, em especial a quimioterapia adjuvante, ainda não foi definida a melhor dose ou o melhor esquema contendo a epirrubicina. Neste artigo, faz-se uma revisão do papel da epirrubicina no tratamento curativo e paliativo do câncer de mama, com ênfase maior na questão da dose deste quimioterápico que deve ser empregada no tratamento adjuvante. Discutem-se os estudos randomizados e as metanálises disponíveis até o presente momento e sugere-se o regime quimioterápico, contendo a epirrubicina, que mais parece adequado ao tratamento.

Effects of low-dose tamoxifen on breast cancer biomarkers Ki-67, estrogen and progesterone receptors

Breast carcinoma is the most common malignancy among women and it has a major impact on mortality. Studies of primary chemoprevention with tamoxifen have generated high expectations and considerable success rates. The efficacy of lower doses of tamoxifen is similar to that seen with a standard dose of the drug, and there has been a reduction in healthcare costs and side effects.

The immune reaction to monoclonal antibody Ki-67 (MIB-1) and the expression of estrogen receptors (1D5) and progesterone receptors (PgR 636) in breast carcinoma were studied in patients treated with 10 mg of tamoxifen for a period of 14 days.

A prospective randomized clinical trial was conducted with 38 patients divided into two groups: Group A: N = 20 (control group-without medication) and Group B: N = 18 (tamoxifen/10 mg/day for 14 days). All patients signed an informed consent term previously approved by both institutions. Patients underwent incisional biopsy before treatment and 14 days later a tumor tissue sample was obtained during surgical treatment. Positivity was quantitatively assessed, counting at least 1.000 cells per slide. For statistical data analysis, a Wilcoxon non-parametric test was used, and α was set at 5%.

Both groups (A and B) were considered homogeneous regarding control variables. In Group A (control), there was no statistically significant reduction in Ki-67 (MIB-1) (p = 0.627), estrogen receptor (1D5) (p = 0.296) and progesterone receptor positivity (PgR 636) (p = 0.381).

In Group B (tamoxifen 10 mg/day), the mean percentage of nuclei stained by Ki-67 (MIB-1) was 24.69% before and 10.43% after tamoxifen treatment. Mean percentage of nuclei stained by estrogen receptor (1D5) was 59.53% before and 25.99% after tamoxifen treatment. Mean percentage of nuclei stained by progesterone receptor (PgR 636), was 59.34 before and 29.59% after tamoxifen treatment. A statistically significant reduction was found with the three markers (p < 0.001).

Tamoxifen significantly reduced monoclonal antibody Ki-67 (MIB-1), estrogen receptor (1D5) and progesterone receptor positivity (PgR 636) in the breast epithelium of carcinoma patients treated with a 10 mg dose of tamoxifen for 14 days.

Effects of raloxifene on normal breast tissue from premenopausal women

The objective of this study was to evaluate the effects of raloxifene on normal breast tissue. A randomized, double-blind study was carried out in 30 ovulatory, premenopausal women of 18-40 years of age, who had been diagnosed with fibroadenoma of the breast. The patients were divided into two groups: Group A (placebo, n = 16) and Group B (raloxifene 60 mg, n = 14). The medication was given for 22 days, beginning on the first day of the menstrual cycle. An excisional biopsy was carried out on the 23rd day during which a sample of normal breast tissue was collected to evaluate the presence of the proliferating cell marker Ki-67. Student's t-test was used for the statistical analysis of data (p < 0.05). Mean percentage of stained nuclei in groups A and B was 10.96 +/- 1.27 and 1.21 +/- 0.26, respectively (p < 0.001). Raloxifene significantly reduced the proliferative activity of normal breast tissue in premenopausal women.

Quantification of angiogenesis induced in rabbit cornea by breast carcinoma of women treated with tamoxifen

BACKGROUND

The aim of this study was to evaluate the effect of tamoxifen on angiogenesis induced in rabbit cornea by breast carcinoma from post-menopausal women.

METHODS

Thirteen post-menopausal women with operable, estrogen receptor-positive breast carcinomas, treated with 20 mg of tamoxifen daily for 30 days prior to undergoing definitive surgery, participated in this study. Twenty-six virgin female New Zealand white rabbits, 3-4 months old, weighing approximately 2.5 kg each, were divided into two groups of 13 animals and received corneal implants of tumor either pre- or post-tamoxifen treatment. After 10 days, the animals were sacrificed, the region of the cornea between the tumor implant and the limbus was removed and quantification of angiogenesis was carried out by evaluating the entire hematoxylin-eosin stained slide, using a 10x objective lens (100x magnification). Student t-test was used in the statistical analysis of the data and statistical significance was established at P < 0.05.

RESULTS

Mean microvessel count was 106.8 +/- 5.9 pre-tamoxifen treatment and 54 +/- 5.6 post-treatment. According to Student t-test, there was a significant reduction in mean microvessel density following treatment with tamoxifen (P < 0.001).

CONCLUSIONS

Rabbit cornea proved to be an interesting experimental model for the quantification of angiogenesis. Tamoxifen, when administered for 30 days to post-menopausal women with breast cancer, significantly inhibited angiogenesis induced by tumor fragments in rabbit cornea.

Differential gene expression assessed by cDNA microarray analysis in breast cancer tissue under tamoxifen treatment

Our purpose was to identify tamoxifen (TAM) responsive genes after 30 days of TAM treatment in tumor tissues obtained from women with breast cancer using microarray expression analysis. In our study, we identified 12 candidates to be considered as tamoxifen-modulated genes. Among them, we selected two candidates the TEGT BI-1 (testis enhanced gene transcript Bax Inhibitor-1) and the CD63 gene in order to further confirm their differential expression under tamoxifen effects. We observed that both were down-regulated in tumor tissues of patients during TAM treatment. TEGT is able to inhibit the expression of Bax, which is known to promote apoptosis. On the other hand, CD63 encodes a cell membrane protein and it seems to be involved in mechanisms of platelet activation, cell adhesion and cell motility. We therefore hypothesize that TAM would be able to modulate tumor growth by down-regulating genes involved in mechanisms such as cell cycle control, tumor invasion and metastasis.